Gender Bias and Perceptions of the Nursing Profession in Croatia: A Cross-Sectional Study Comparing Patients and the General Population

Abstract

Background

The way the nursing profession is perceived plays a pivotal role in shaping the public's attitude toward its members, primarily influenced by interactions with nurses and media representation. However, it can be significantly impacted by historical and traditional stereotypes, coupled with enduring gender bias and other preconceived notions.

Objectives

The study aimed to examined how the title “nurse” reflects the profession's identity, perception as a female occupation, and status as a healthcare activity. It also assessed awareness of nurses’ roles, education and public presence, comparing general population and patients’ opinions in the Republic of Croatia.

Methods

Conducted as a cross-sectional study, this research employed a structured questionnaire and a convenience sampling approach. It encompassed both the general population and patients from Croatia, with data collection spanning from February 15, 2023, to March 16, 2023, and resulting in a total sample size of 624 participants. Statistical analysis included both descriptive and inferential techniques, and significance was set at p < .01 (two-tailed).

Results

A substantial proportion of respondents, amounting to 38.1%, correlate the term “nurse” with the role of the physician's assistant, whereas only 49.5% associate it with a true professional functioning within their field of work. Furthermore, 73.7% study participants perceive the nursing profession as being desirable for men. Upon examining the perspectives of the general population and patients, statistically significant differences emerged in terms of their perceptions regarding the perceived work scope (p < .001) and the level of sufficient educational attainment (p < .001) of nursing professionals.

Conclusion

The analysis uncovers varying perceptions of the nursing profession in the Republic of Croatia, as well as evolving perceptions of gender diversity within nursing roles. Differing viewpoints between the general population and patients in this study emphasize the need for tailored education and communication initiatives to improve the image of nursing.

Keywords

nursing nursing profession nurse perception gender bias cross-sectional study

Introduction

The way the public perceives nursing is extremely important, as it plays a key role in the social recognition and visibility of the profession (Takase et al., 2002). In Croatia, a national study conducted in 2010 (with a sample of 3005 participants) explored the public perception of nursing profession, with the aim to asses citizen satisfaction with public services and the quality of services provided (EIZ, 2011). In short, nursing professionals received the highest average rating of 3.24 (EIZ, 2011). A Gallup poll in the United States in 2021 revealed that nurses had been ranked as the most trusted health professionals for the twentieth consecutive year, with 81% of respondents’ votes—surpassing the military, physicians, and teachers (Gallup, 2022). Donelan et al. (2008) also found that nursing is viewed positively, with 1604 participants expressing a high level of respect for nursing and endorsing it as a potential career path.

However, the public perception of nurses is not limited solely to positive aspects. In other words, it is influenced by stereotypes and prejudices, some of which have historical roots, while others are tied to gender, social, and cultural aspects (Cunningham, 1999). A prevalent stereotype is that nursing is exclusively associated with women, stemming from a historical context where caregiving for the sick and family was traditionally a mother's role (Andrist et al., 2006). Dalborg-Lyckhage and Pilshmar-Anderson's research (2009) in Sweden indicated an unfavorable perception of nurses within the context of gender discourse, depicting nursing occasionally as a profession linked to the female gender identity.

This underscores the challenges that male professionals within the nursing field face (Evans, 2002). Despite these challenges, it has been noted that men enter the nursing profession for the same reasons as women—to care for the sick and those in need (O'Lynn & Tranbarger, 2006). The available data indicate that, in Canada, only 5% of nursing professionals are male, while those numbers are 10% and 4% in England and Ireland, respectively (Zamanzadeh et al., 2013). The highest percentage (23%) is found in Iran (Zamanzadeh et al., 2013). Prejudices and stereotypes faced by male nurses often involve assumptions of less compassion and empathy compared to female counterparts or a perception of femininity; such stereotypes are rooted in traditional gender roles, expectations, and societal norms (Arif & Khokhar, 2017; Stanley et al., 2016), compounded by the linguistic characterization of the profession (Abou Aldan, 2022).

Nursing professionals also contend with the perception that their roles are less important and less professional compared to physicians. This is captured by patient sentiments like “the public may love angels but stick to the stronger ones, the doctors” (Kalauz, 2011). They are often perceived as caring, feminine, and sociable, placing them in the realm of familial caregiving. In contrast, physicians are perceived as individualistic and autonomous (Takase et al., 2002). A study by Helimch et al. (2010) revealed that medical students, prior to their clinical practice, also perceived nurses in this manner; however, post-practice they recognized nursing professionals to possess more responsibility and expertise than initially anticipated. However, according to de Meis et al. (2007), nurses are still not universally regarded as healthcare professionals, shaping a public image of nursing as a secondary role tied to another profession (i.e., medicine). This perception denies them responsibility, autonomy, and apposite decision-making capacity (Sánchez-Gras, 2017).

Kalauz (2011) also points to research describing the public perception of nurses as inadequately educated, less intelligent, and hesitant to assume responsibility. This perspective contradicts the high expertise and competencies nurses possess. Although the public recognizes the crucial role of nurses in the healthcare system, which was especially evident during coronavirus disease 2019 (COVID-19) pandemic when a positive correlation emerged between the public's perceptions and attitudes toward nursing, as opposed to other professions, and when there was a general acknowledgment that nurses possess a unique competence that cannot be replicated by other professionals (Blau et al., 2022; Rubbi et al., 2023).

Nonetheless, stereotypes and biases continue to misrepresent their status. This is partly because emotional expression in nursing is often seen as separate from autonomy, leading to perceptions that the emotional aspects make the profession less valuable and subordinate to others (Kalauz, 2011). However, this emotional component renders nursing practice more compassionate and rather unique (Kalauz, 2011).

Review of Literature

The current state of affairs is not happenstance, but rooted in history (Egenes, 2017). The aforementioned notion sparked the idea of research rooted in the understanding of the historical context of nursing, serving as a foundation to comprehend the position, role, and identity of nursing professionals today. Since the beginning of early communities, the responsibility for caring for the sick, helpless, children, and the elderly (as experiential tasks) was typically assigned to women—frequently mothers (Čukljek, 2005). However, with the development of early civilizations, men began to engage in patient care (Kalauz, 2011). In Indian literature, author Charaka described the concept of team-based work, previously unknown to medicine, and mentioned nurses as members of the team, alongside physicians and patients (Kalauz, 2011). Historical records from 250 BC indicate that men were the initial caregivers for the sick in India, believed to be sufficiently “pure” to perform such tasks; thus, the term “nurse” referred to the male gender (Christensen, 2018).

Early Christianity influenced the development of a positive value system among people, fostering a nursing ideal of compassion, selflessness, and service to others (Egenes, 2017; Kalauz, 2011). Deaconesses were the earliest religious sisters of the Catholic Church whose purpose was to assist priests in caring for the sick and the poor, providing women with meaningful participation in the work of the Church (Kreutzer & Nolte, 2016). “Matrone” referred to a group of wealthy Roman noblewomen in the fourth century who transformed their homes into hospitals and hospices, signifying the incipient phases of structured care for the ill (Egenes, 2017; Kalauz, 2011).

However, during humanism and the Renaissance (i.e., between thirteenth and sixteenth century) religious beliefs were discarded under the influence of new scientific insights, along with caregiving founded on religious teachings of helping, welfare, and compassion (Kalauz, 2011). This trend persisted into the era of Florence Nightingale (1820–1910), who grounded her knowledge in facts and statistical data obtained through research (Kalauz, 2011), earning her the title of nursing reformer and founder of professionalism-based nursing (Egenes, 2017). Nevertheless, her description of nurses as motherly figures (i.e., protective, caring and kind) marked the era of nursing's feminization, with lingering consequences even today (Stanley et al., 2016).

The traditional association with women's societal roles and historical influences also led to dilemmas regarding the title and profile of nurses (Kalauz, 2011; Mojsović, 2005). Since 1940, the Croatian term for a healthcare provider has been “medicinska sestra,” where the adjective “medicinska” derives from the Latin word “medicus” (physician)—suggesting the role and responsibility of medical nurses in supporting physicians (Abou Aldan, 2022). The noun “sestra” (i.e., sister) suggests religious influence, reflecting the historical association of nursing with caregiving and the supportive role akin to that of a sister within religious communities (Mojsović, 2005). In English, which is considered the original professional language of nursing, the fundamental term is a “nurse” (Abou Aldan, 2022). This term originates from the Old French word “nourice,” rooted in the Late Latin “nutricius”—which literally means a person who nurses or feeds (Abou Aldan, 2022). Until the fourteenth century, the term referred to a person caring for children, and from the sixteenth century onward, it referred to an individual (usually a woman) caring for the sick (Abou Aldan, 2022). Florence Nightingale herself, in her book “Notes on Nursing: What It Is and What It Is Not,” published in 1859, mentioned using the term due to a lack of a better one (Abou Aldan, 2022). But the question remains—is this actually the most fitting designation for the profession as a whole?

A recent, very comprehensive integrative review identified two distinct categories of stereotypes: those linked to the gender identity of nursing professionals and those tied to the perceived characteristics of the nursing profession itself (Teresa-Morales et al., 2022). Nursing is often perceived as a low-skilled, low-prestige and inadequately compensated field with minimal academic requirements, lacking autonomy and seen as subordinate to medicine. Moreover, societal devaluation of nursing work, particularly because it is associated with women, continues to impede its recognition. Male nurses face challenges to their masculinity and professional competence, with more patriarchal religious and cultural contexts amplifying these stereotypes (Teresa-Morales et al., 2022).

In light of the aforementioned issues, this study aimed to examine whether the title “nurse” adequately reflects the identity, integrity, and autonomy of the nursing profession. It also explored whether the title influences the perception of nursing as a female occupation and whether respondents perceive nursing as a professional healthcare activity. Additionally, the study assessed participants’ awareness of the scope of work and education level of nursing professionals, and whether there is a statistically significant difference in responses and opinions between the general population and patients regarding their scope of work, education, and public/media presence.

Methods

Study Design

This study employed a cross-sectional research design, which involved gathering data at a single point in time with structured questionnaire as an instrument. The study utilized a convenience sampling approach due to its practicality and ease of access to potential participants. To ensure methodological rigor and adherence to best practices, the research adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines tailored for cross-sectional studies (Cuschieri, 2019). There were two main groups of participants envisioned for this study: (1) the general population and (2) the patient population. This bifurcation aimed to capture a comprehensive view of perceptions related to the nursing profession, and by including both these groups, we sought to highlight variations in perception that might arise due to different vantage points. The intention was to obtain quantitative data about the perception of the nursing profession from two distinct perspectives and to identify statistically significant differences between the two participant groups.

The Research Instrument

The structured questionnaire, available both in physical and online format, was self-developed by this research group and consisted of five identical sets of questions. The first part of the questionnaire pertained to sociodemographic data and the perception of the interaction between nursing professionals and the social environment (Question sets I and II). The second part of the survey questionnaire (Question sets III, IV, V) focused on the perception of nursing as a profession, the perception of education for nursing professionals, and their perception in the public life and media. A Likert scale with five response points was utilized in the mentioned questions, ranging from 1 (strongly disagree) to 5 (strongly agree). The questions in the questionnaire were designed to require one or two responses. Two experts in the field reviewed the survey and provided feedback on questions, agreeing that they adequately represent the construct intended for measurement, establishing content validity of the survey. Individuals who were representative of the intended survey audience, but not the experts in the field, were asked to review the questionnaire. The goal was to ensure that the questions were easily understood and relevant for this study.

Research Questions

Research questions aim to address the study's objectives and explore the nuances of perception related to the nursing profession from both the general population and patient perspectives.

To what extent does the title “nurse” accurately reflect the identity, integrity, and autonomy of the nursing profession?

How does the title “nurse” influence perceptions of nursing as a predominantly female profession?

Do respondents perceive nursing as a professional healthcare activity, and does this perception differ based on their background?

What is the level of awareness among participants regarding the scope of work and educational levels of nursing professionals?

What is the perception of study participants in regard to the exposure of nursing professionals in public life and media?

Are there statistically significant differences in responses and opinions about nursing profession-related aspects between the general population and patients?

Sampling Design and Data Collection Procedure

A convenience sampling approach was undertaken for the purposes of this study. The sample size was determined by power analysis with large effect size of 0.3, power of 0.9, and alpha value at 0.01 (two-tailed level of significance). According to the calculation, a minimum total sample size of 369 was required. Among the patient participants, a total of 315 questionnaires were distributed in physical form to users of the healthcare institution, residents of the elderly care home, and members of one NGO for individuals affected by diabetes. The institutional names are treated as confidential information. Among these, 306 questionnaires were satisfactorily filled out, reflecting an excellent response rate. For the general population participants, an online questionnaire was created using a form-building tool and conducted via Google Forms. The survey was distributed on through networking and social media channels from February 15, 2023, to March 16, 2023.

Inclusion/Exclusion Criteria

The inclusion criteria for this study entailed participants that were aged 18 years and older, those residing within the geographic area of interest (i.e., in Croatia), fluent in the language of the survey instrument (which is a local language), and who voluntarily agreed to participate in the study. The general population refers to individuals who are not specifically categorized as patients seeking medical care; it encompasses a diverse group of people from various backgrounds and occupations who may or may not have direct interactions with healthcare professionals. The patient population refers to individuals who have received medical care and have interacted with nursing professionals within the healthcare system; this group is specific to those who have firsthand experience with healthcare services. Exclusion criteria were as follows: participants under the age of 18, individuals residing outside the geographic area of interest, participants with limited understanding of the survey language, individuals who are not eligible to participate based on the predetermined criteria, participants with cognitive impairments that might affect their ability to comprehend and respond to the survey, individuals who decline or are unwilling to participate in the study, and in the patient group, those who have not interacted with nursing professionals or received medical care. All survey participants had to provide a statement in regard to inclusion and exclusion criteria prior to commencing with the survey. Before beginning the survey, all participants were required to declare their compliance with the specified inclusion and exclusion criteria.

Ethical Considerations

The research was conducted in accordance with the ethical standards of the institutional research board. Permissions to conduct the research were granted by the authors’ academic institution, University North in Croatia (under a thesis reference number 234/SSD/2023). All procedures that were followed adhered to the ethical standards of the Helsinki Declaration from 1975 and its revision in 2000. Written approval for questionnaire distribution was obtained from the healthcare institution and the NGO for individuals affected by diabetes. Additionally, approval was obtained from the Ethics Committee of the elderly care home. In both statements, the researchers committed to upholding the principles of data confidentiality, using the obtained data solely for the purpose of the specified research, and ensuring that published data would not allow the identification of any individual who participated in the study. All research participants were informed verbally and in writing about the purpose of the research and inclusion criteria, and by signing the informed consent, they confirmed their voluntary participation in the study.

In an online version of the survey, the research project, its aims, and the importance of the study were communicated through networking and social media channels. Details concerning the survey's title, confidentiality, data privacy, and participant anonymity were also provided. Furthermore, the researchers’ contact details were shared for any queries or clarifications. An electronic consent form was part of the online survey. All gathered electronic data were securely stored on a computer protected by a password.

Statistical Analysis

For data analysis, the IBM Statistical Package for the Social Sciences (IBM SPSS) Statistics for Windows, Version 25.0. (Armonk, NY: IBM Corp.) software was used. The data were processed using descriptive statistics methods: frequencies (f), percentages (%), medians (C), and measures of variability (interquartile range-Q3-1), and presented in tabular forms. Differences and dependencies in responses, opinions, and attitudes between the two groups of participants were tested using the chi-square test and a series of Mann–Whitney U tests (inferential statistics). Significance level was set at p less than .01 (two-tailed).

Results

Sample Characteristics

A total of 624 participants (N = 624) took part in the study, of which 318 (51%) constituted the general population, and 306 (49%) represented the patient group. Among the patients, the largest number of respondents, that is, 244 of them (79.7%), utilized the services of nursing professionals during diagnostic-therapeutic procedures at home; furthermore, 33 (10.8%) of them were institutionalized in nursing homes, whereas 29 of them (or 9.5%) were members of the nongovernmental organization (NGO) for individuals affected by diabetes. In terms of gender, female participants were the most represented group in this study (447 or 71.6%), followed by 174 male participants (27.9%) and three (0.5%) participants that preferred not to disclose their gender. The most prevalent age group was 60 years and older (42%), while in terms of education level, the highest number of participants had completed high school (i.e., 313 of them or 50.2%), followed by undergraduate studies (21%). The full breakdown of sociodemographic variables in the total sample is presented in Table 1.

Table 1.

Sociodemographic Characteristics of Study Participants.

Gender	Number	Percentage (%)
Male	174	27.9
Female	447	71.6
Prefer not to disclose / Other	3	0.5
Total	624	100.0
Age
18–29 years	100	16.0
30–40 years	88	14.1
40–50 years	93	14.9
50–60 years	81	13.0
60 years and older	262	42.0
Total	624	100.0
Education level
Completed elementary school	113	18.1
Completed high school	313	50.2
Completed undergraduate studies	131	21.0
Completed graduate studies	55	8.8
Completed postgraduate studies	12	1.9
Total	624	100.0

Descriptive Analysis of Research Questions

From a total of 624, basically half of the participants associate the term “nurse” with the concept of a professional working in their field, whereas 38.1% of them associate the term with the concept of the physician's assistant. Conversely, the smallest number of participants, 77 of them (or 12.3%), opted for leader in the healthcare system (Table 2). In addition, the majority of respondents perceive nursing as a true calling (38.1%) and as a vocation (35%), while only 13.9% perceive it as an independent profession. A smaller number of respondents view nursing as an auxiliary healthcare activity (10.1%) and exclusively as a female profession (3%) (Table 3). Interestingly, 460 (73.7%) participants believe that the nursing profession is desirable for males, while 164 (26.3%) participants hold an opposing view.

Table 2.

The Overall Perception of the Term “Nurse” for Describing a Nursing Professional.

I associate the term “nurse” with the concept of:	f	%
Professional working in their field	309	49.5
Physician's assistant	238	38.1
Leader in the healthcare system	77	12.3
Total	624	100.0

Table 3.

Study Participant Responses Regarding the Perception of Nursing.

I perceive nursing as a:	f	%
True calling	238	38.1
Vocation	215	34.5
Independent profession	87	13.9
Auxiliary healthcare activity	63	10.1
Exclusively a female profession	21	3.4
Total	624	100.0

Based on median values, it was determined that both the surveyed general population and patients agree at a relatively high level (C = 4) that nursing profession has the characteristics of a service activity and that nursing professionals follow physicians’ orders without questioning them. Moreover, the perception of educational and scientific path for nursing professionals is quite favorable, while most respondents strongly agree that nursing professionals should engage more in the public sphere and that they are underrepresented in the media (when compared to other stakeholders in healthcare). A detailed breakdown of results can be seen in Tables 4–6.

Table 4.

Assessment of Statements Examining the Perception of Nursing as a Profession.

		Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	C	Q₃₋₁
		1	2	3	4	5	C	Q₃₋₁
1. Nursing is a respected profession in society.	f	92	87	112	141	192	4.00	3.00
1. Nursing is a respected profession in society.	%	14.7	13.9	17.9	22.6	30.8
2. Nursing is a vocation, not a profession.	f	98	74	149	131	172	3.00	3.00
2. Nursing is a vocation, not a profession.	%	15.7	11.9	23.9	21.0	27.6
3. Nursing is equally suitable for men and women.	f	21	29	46	136	392	5.00	1.00
3. Nursing is equally suitable for men and women.	%	3.4	4.6	7.4	21.8	62.8
4. Nursing has the characteristics of a service activity.	f	119	43	106	172	184	4.00	3.00
4. Nursing has the characteristics of a service activity.	%	19.1	6.9	17.0	27.6	29.5
5. Nursing is an extremely demanding profession that is not sufficiently appreciated.	f	10	2	19	95	498	5.00	0.00
	%	1.6	0.3	3.0	15.2	79.8
6. Nursing care is indispensable in patient recovery.	f	4	7	15	106	492	5.00	0.00
6. Nursing care is indispensable in patient recovery.	%	0.6	1.1	2.4	17.0	78.8
7. Nursing professionals are given the opportunity to use their own initiative in their work.	f	64	106	182	127	145	3.00	2.00
	%	10.3	17.0	29.2	20.4	23.2
8. Nursing professionals follow physicians’ orders without questioning them.	f	35	54	137	189	209	4.00	2.00
	%	5.6	8.7	22.0	30.3	33.5
9. Nursing professionals do not use a significant portion of their working time productively.	f	217	93	147	77	90	3.00	3.00
	%	34.8	14.9	23.6	12.3	14.4
10. Anyone could do the job of a nursing professional.	f	384	100	56	38	46	1.00	1.00
10. Anyone could do the job of a nursing professional.	%	61.5	16.0	9.0	6.1	7.4
11. I would like my child to become a nursing professional.	f	141	65	188	83	147	3.00	2.00
11. I would like my child to become a nursing professional.	%	22.6	10.4	30.1	13.3	23.6
12. I would prefer to seek advice regarding my health condition or issue from a nursing professional rather than a doctor.	f	80	81	142	137	184	4.00	3.00
	%	12.8	13.0	22.8	22.0	29.5
13. I find it easier to communicate with a female nursing professional than with her male counterpart.	f	199	74	129	99	123	3.00	3.00
	%	31.9	11.9	20.7	15.9	19.7
14. Nursing professionals are adequately compensated for the work they do.	f	358	83	82	41	60	1.00	2.00
	%	57.4	13.3	13.1	6.6	9.6
15. Nursing professionals are more compassionate than other healthcare personnel.	f	35	34	115	158	282	4.00	2.00
	%	5.6	5.4	18.4	25.3	45.2

Table 5.

Assessment of Statements Examining the Perception of Education for Nursing Professionals.

		Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	C	Q3-1
		1	2	3	4	5
1. Nursing professionals are less educated compared to physicians.	f	168	77	136	117	126	3.00	3.00
	%	26.9	12.3	21.8	18.8	20.2
2. Nursing professionals can pursue education at all levels of academic degrees (bachelor's, master's, doctoral).	f	5	9	58	148	404	5.00	1.00
	%	0.8	1.4	9.3	23.7	64.7
3. Nursing professionals can write and publish research papers.	f	11	36	69	145	363	5.00	1.00
	%	1.8	5.8	11.1	23.2	58.2
4. Nursing professionals define nursing diagnoses for each patient, just like medical doctors define medical diagnoses.	f	42	79	116	122	265	4.00	2.00
	%	6.7	12.7	18.6	19.6	42.5
5. Nursing professionals instill trust in their expertise and competencies.	f	4	12	57	198	353	5.00	1.00
	%	0.6	1.9	9.1	31.7	56.6

Table 6.

Assessment of Statements Examining the Perception of Nursing Professionals in the Public Life and Media.

		Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	C	Q3-1
		1	2	3	4	5	C	Q3-1
1. Nursing professionals should engage more in the public sphere since they possess the necessary academic education for it.	f	6	25	85	188	320	5.00	1.00
	%	1.0	4.0	13.6	30.1	51.3
2. Nursing professionals are underrepresented in the media in comparison to other healthcare workers.	f	16	28	84	162	334	5.00	1.00
	%	2.6	4.5	13.5	26.0	53.5
3. Nursing professionals have limited representation in the realm of politics.	f	49	32	131	108	304	4.00	2.00
	%	7.9	5.1	21.0	17.3	48.7

Inferential Analysis of Research Questions

The chi-square test was initially conducted to examine the difference in responses between patients and the general population regarding the scope of work of nursing professionals, as well as the optimal level of education. A statistically significant difference was found in the perception of the scope of work of nursing professionals between the two groups of respondents (patients vs. general population) (χ² = 43.89; df = 1; p < .001). More specifically, both groups of respondents had a high percentage of accurate answers regarding the scope of work of nursing professionals as professional, evidence-based patient care (a total of 523 correct responses or 83.8%). However, in the patient group, there were more incorrect answers (26.1%) compared to the general population (6.6%). Furthermore, it can be observed that a majority of respondents in the total sample (330 responses or 52.9%) agreed with the statement that the high-school level of education is sufficient for performing nursing activities in the Republic of Croatia. Nevertheless, a statistically significant difference was also found between patients and the general population (χ² = 31.84; df = 1; p < .001). The majority of respondents (64.4%) in the patient group believed that the education of nursing professionals in Croatia is sufficient for performing nursing activities at the high-school education level, while in the general population group, the majority of respondents (58.2%) held the opposite opinion and believed that nursing professionals should have bachelor degree or even a higher level of education for performing quotidian nursing activities.

In order to examine the differences in opinions between the general population and patients regarding the scope of work and education level of nursing professionals, a series of Mann–Whitney U tests were conducted. Differences in their level of agreement were examined across 15 statements related to the mentioned two areas. The results are presented in Table 7.

Table 7.

Differences in the Opinion of the General Population and Patients Regarding the Scope of Work and Education Level of Nursing Professionals.

Claim		N	Average rank	Sum of ranks	Mann–Whitney U	Z	p
Nursing has the characteristics of a service activity.	Patients	306	356.38	109,051.50	35,227.50	−6.15	<.001
	General population	318	270.28	85,948.50
	Total	624
Nursing care is indispensable in patient recovery.	Patients	306	294.87	90,230.50	43,259.50	−3.37	<.001
	General population	318	329.46	104,769.50
	Total	624
Nursing professionals are given the opportunity to use their own initiative in their work.	Patients	306	299.54	91,660.50	44,689.50	−1.81	.07
	General population	318	324.97	103,339.50
	Total	624
Nursing professionals follow physicians’ orders without questioning them.	Patients	306	336.67	103,019.50	41,259.50	−3.42	<.001
	General population	318	289.25	91,980.50
	Total	624
Nursing professionals do not use a significant portion of their working time productively.	Patients	306	287.64	88,018.50	41,047.50	−3.49	<.001
	General population	318	336.42	106,981.50
	Total	624
Anyone could do the job of a nursing professional.	Patients	306	326.06	99,775.00	44,504.00	−2.11	.03
	General population	318	299.45	95,225.00
	Total	624
I would prefer to seek advice regarding my health condition or issue from a nursing professional rather than a doctor.	Patients	306	307.65	94,142.00	47,171.00	−0.68	.50
	General population	318	317.16	100,858.00
	Total	624
Nursing professionals are adequately compensated for the work they do.	Patients	306	327.06	100,080.00	44,199.00	−2.21	.03
	General population	318	298.49	94,920.00
	Total	624
Nursing professionals are less educated compared to physicians.	Patients	306	325.85	99,710.50	44,568.50	−1.86	.06
	General population	318	299.65	95,289.50
	Total	624
Nursing professionals can pursue education at all levels of academic degrees (bachelor's, master's, doctoral).	Patients	306	270.24	82,692.00	35,721.00	−6.80	<.001
	General population	318	353.17	112,308.00
	Total	624
Nursing professionals can write and publish research papers.	Patients	306	273.98	83,838.50	36,867.50	−5.89	<.001
	General population	318	349.56	111,161.50
	Total	624
Nursing professionals define nursing diagnoses for each patient, just like medical doctors define medical diagnoses.	Patients	306	261.94	80,152.50	33,181.50	−7.22	<.001
	General population	318	361.16	114,847.50
	Total	624
Nursing professionals instill trust in their expertise and competencies.	Patients	306	310.89	95,131.50	48,160.50	−0.25	.80
	General population	318	314.05	99,868.50
	Total	624
Nursing professionals should engage more in the public sphere since they possess the necessary academic education for it.	Patients	306	287.25	87,897.50	40,926.50	−3.76	<.001
	General population	318	336.80	107,102.50
	Total	624
Nursing professionals have limited representation in the realm of politics.	Patients	306	309.14	94,597.50	47,626.50	−0.49	.62
	General population	318	315.73	100,402.50
	Total	624

Greater agreement among patients than the general population was observed for the following statements: Nursing has characteristics of a service profession (Mann–Whitney U = 35,227.50; p < .001), Nursing professionals follow physicians’ orders without questioning them (Mann–Whitney U = 41,259.50; p < .001), Anyone could do the job of a nursing professional (Mann–Whitney U = 44,504.00; p = .03), and Nursing professionals are adequately compensated for the work they do (Mann–Whitney U = 44,199.00; p = .03).

Greater agreement among the general population was expressed for the statements: Nursing care is indispensable in patient recovery (Mann–Whitney U = 43,259.50; p < .001), Nursing professionals do not use a significant portion of their working time productively (Mann–Whitney U = 41,047.50; p < .001), Nursing professionals can pursue education at all levels of academic degrees (bachelor's, master's, doctoral) (Mann–Whitney U = 35,721.00; p < .001), Nursing professionals can write and publish research papers (Mann–Whitney U = 36,867.50; p < .001), Nursing professionals define nursing diagnoses for each patient, just like medical doctors define medical diagnoses (Mann–Whitney U = 33,181.50; p < .001), and Nursing professionals should engage more in the public sphere since they possess the necessary academic education for it (Mann–Whitney U = 40,926.50; p < .001).

In conclusion, a statistically significant difference in opinions and responses between the two groups of participants regarding the scope of work and education level of nursing professionals was, therefore, identified in 10 out of a total of 15 statements.

Discussion

This study aimed to explore how the general public and patients perceive the nursing profession; more specifically, it examined their understanding of nurses’ roles and educational backgrounds, and considered how the professional titles of nurses impact the view of nursing as both a profession and a traditionally female-dominated field. The results have revealed that as much as 38.1% of respondents associate the term “nurse” with the concept of the physician's assistant, while only 49.5% relate it to a frank professional operating within their field of work. This question emerged from the dilemma surrounding the traditional term “nurse,” which arguably does not provide clear information about who that person is and their scope of work, as is the case with other healthcare professionals (such as such as physicians, pharmacists, or physical therapists). The result is unsurprising and aligns with a 2014 study conducted in Croatia, which identified an even higher percentage; specifically, 63% of respondents in that study believed that nurses were in fact physician's assistants (Dragičević, 2014). This suggests that there is a true linguistic determinism influencing the perception of the role of a nurse, which may be influenced by cultural nuances and regional variations. Such idea is consistent with the widely accepted understanding that cultural contexts greatly influence attitudes and beliefs, especially within healthcare settings.

Considering that the notions of vocation and true calling are characteristic of religious orders, the historical influence of the charitable activities of such orders and movements is evident in the fact that a significant number of respondents perceive nursing as a true calling (38.1%) and a vocation (34.5%), while only 13.9% perceive it as an independent profession. Therefore, it can be concluded that the religious origins of nursing significantly influence its perception. This was also confirmed by the research conducted by the author Marković (2018), where the majority of respondents (41.7%) expressed that they perceive the nursing profession as a true calling. In a comprehensive study conducted by Siebens et al. (2006), it was found that 73.4% of nurses believe that society perceives nursing more as a calling than as a profession. This suggests that this profession remains deeply influenced by traditional values, which positively emphasizes the humanistic approach and strengthens the moral and ethical framework within which nurses work. However, on the other hand, it limits the potential for professional advancement.

Interestingly, more than 70% of respondents in our study consider the nursing profession desirable for individuals of male gender, which is in complete contrast to the research conducted by Ten Hoeve et al. (2014) in China, where it was found that parents would not encourage their own children—especially sons—to enter the profession. This may be supported by a recent study by Boge et al. (2019), which showed that patients still exhibit gender bias in their perceptions of male nursing professionals. Specifically, the study found that male nurses were recognized as nurses by patients 77.1% of the time, compared to 91.1% for female nurses, a difference that was statistically significant (Boge et al., 2019). Still, in another study from Croatia, Licul and Popović (2015) comparably showed that the majority of respondents did not support the statement that nursing is exclusively a female profession, with less than 50% of respondents agreeing that nursing is more suitable for women. This result suggests a gradual decrease in gender segregation due to traditional beliefs and indicates positive trends in the inclusion of male healthcare professionals in the nursing field.

All respondents showed a relatively high level of agreement with the statement that nursing exhibits characteristics of a service activity. Based on the established difference in perception between the general population and patients, nursing is perceived more as a service activity by the patients. One possible reason for this could be the lack of emphasis on the importance of nursing professionals’ roles in the public eye, leading to an oversimplified view of their work as merely providing services without recognizing the wide range of tasks involved in caregiving. Since patients most commonly experience nursing through this service-oriented component during their medical care, they may well develop the perception that nursing is primarily a service activity.

The research results also revealed that the general population, to a greater extent than the patients, agreed with the statement that nursing care plays a pivotal, indispensable role in the recovery of a sick individual. This suggests that the general population possesses a broader perception and awareness of the role of nursing professionals in the healthcare process, recognizing their significance in patient recovery. On the other hand, patients, being directly involved in the treatment process, may have a more subjective experience and focus on other aspects of care, such as medical procedures or interactions with doctors, which can elevate the disease treatment above healthcare itself—leading to a perception that nursing care is not crucial in the recovery process. Still, a recent integrative review by Rodríguez-Pérez et al. (2022) has reinforced the notion of general public's lack of awareness about the contemporary academic, scientific, and professional landscape of nursing, which often results in misconceptions and misrepresentations of the nursing profession. Consequently, nursing competencies tend to be either unnoticed or underestimated by society.

In 83.8% of cases, both the general population and patients correctly identified the area of work of nursing professionals as patient care. However, in the patient group, there was a higher percentage of incorrect responses, totaling 26.1%. One possible reason could be the patients’ frequent focus on their own illness, leading to a lack of awareness about the wide range of services and activities provided by nursing professionals—such as education, counseling, care coordination, healthcare resource management—and the persistent perception of nursing as an auxiliary activity alongside physicians.

Hence, participants in the overall sample also strongly agreed with the statement that nursing professionals follow doctors’ orders without questioning them. Based on the noted disparity in viewpoints, patients generally agreed with this statement, suggesting a perception of nursing professionals having subordinate roles and implying a lack of autonomy within the nursing profession. This result is consistent with a study conducted in 2017 in Croatia, which found that, although nursing professionals perceive themselves as an autonomous profession with their own expertise, they tend to follow physicians’ instructions—even when they believe those instructions are incorrect (Sule, 2018). This reflects the challenges nursing professionals face in decision-making during quotidian care process.

Also, in traditional medical environments, physicians are often perceived as authorities and decision-makers, while nursing professionals are considered as those following orders. Such perception is further reinforced by patients’ lack of information about the diversity and autonomy within the nursing profession in the media, which often portrays nursing unrealistically. However, the results of this research clearly support the idea that the general population believes nursing professionals should be more visible in the public sphere, leveraging their academic education for this purpose. The general population was more aligned with this statement than the patients, underscoring the fact that the nursing professionals’ potential to promote healthcare values and represent patient interests in public and political contexts is well-recognized, portraying them as caring guardians who understand their needs. Rodríguez-Pérez et al. (2022) argue that nursing professionals should utilize both conventional media and various social media platforms to develop and improve their media skills, aiming to strengthen their visibility and recognition in the public sphere.

Furthermore, a substantial portion of the respondents (52.9%) agreed with the statement that the education of nursing professionals in Croatia is sufficient for carrying out nursing activities at the high school level, while 47.1% believed that a higher educational level should be required for performing nursing activities. Notably, a larger percentage of patients (64.4%) felt that high school education is sufficient, in contrast to the general population's opinion. This difference could be attributed to the lower educational level of the patient group in our study, which might influence their perception based on their own qualifications. Another factor could be the patients’ perception of the work scope of nursing professionals in nursing homes and health services that they continuously receive in their home, which might seem routine and repetitive to them. Consequently, this could create a false impression of lower complexity of such tasks. However, the practice of nursing encompasses much more than fulfilling patients’ fundamental physiological needs. This highlights the importance of raising awareness about the essential role of higher education in improving the quality of care and the perception of nursing as a profession; more specifically, nursing professionals with advanced education levels can make a more significant contribution to patient care, and there is also an improved integration of professional values into practice (Sibandze & Scafide, 2018). A recent study has also found that the caring behavior of nurses can be improved by increasing their educational attainment (Fikre et al., 2022).

Moreover, it is important to consider patients’ experiences with traditional healthcare models, especially considering that most patient respondents belonged to an older age group. In traditional models, nurses often performed nursing tasks with minimal formal training. This might have led the patient group to lean toward agreeing with the statement that nurses are adequately compensated for their work. Nonetheless, patients were less likely than the general population to agree with the statement that nursing professionals use a significant portion of their working time unproductively. This might be due to their awareness of the demanding physical work that nursing professionals engage in during their care, noticing the time nurses spend in direct communication with patients, providing support, performing procedures, and monitoring their condition on a regular basis.

Still, it is crucial to emphasize that patients might have their own unique perceptions regarding what they deem to be productive work for nursing professionals, based on their expectations, experiences, and needs/requirements. Thus, some activities that nurses undertake (particularly documentation and/or administrative tasks) might be less visible to patients, but remain important for care continuity and patient safety. An ethnographic investigation into the organizational practices that shape home nursing care uncovers that managers’ routine tasks revolve around making specific types of nursing practices noticeable (Purkis, 2001).

Taken together, the results emphasize the necessity for further efforts to acknowledge the role and importance of nursing professionals within the healthcare system, particularly from the patient's viewpoint. This includes aspects such as complexity, expertise, autonomy, and higher education, which should be detached from the influence of societal, historical, and traditional stereotypes and biases related to subordination, women's roles in society, and limited education.

Strength and Limitations

This study comes with several strengths, primarily in broadening our understanding of how the nursing profession is perceived from two distinct perspectives: the general population and patients. This unique approach uncovers a previously unexplored differentiation in perception between these two distinct groups, shedding light on a fresh dimension of understanding. Notably, the study's robustness is further enhanced by its substantial sample size, which contributes to the statistical power and reliability of the findings.

However, alongside these strengths, it is important to acknowledge the limitations inherent to our approach. Firstly, the adoption of a cross-sectional design, while useful for capturing a snapshot of perception, restricts our ability to infer causality between specific statements and the demographic factors of participants. Another relevant point for consideration is the use of a convenient sampling technique for participant recruitment. While this approach facilitated data collection, it introduces a potential bias and restricts the generalizability of the study's outcomes beyond the sampled population (which also highly depends on different cultural contexts). This limitation underscores the need to be circumspect when applying our findings to broader contexts. Furthermore, the utilization of an online survey tool introduces the possibility of desirability bias. In other words, participants might tailor their responses to align with social norms or perceived expectations, potentially skewing the accuracy of certain results. Recognizing this inherent bias helps in framing the study's outcomes in a more nuanced context. We also recognize the potential of nonresponse bias (especially in the online part of the research endeavor), which can potentially affect the validity of the findings.

Implications for Practice

This study implies the necessity to develop promotional activities targeting the general public and to increase the visibility of nursing professionals in the public sphere in order to enhance the perception and understanding of their role. Healthcare institutions should consider adapting their communication strategies to better inform patients about the competencies and responsibilities of nursing professionals, who should also raise awareness among patients through day-to-day communication. Furthermore, promoting academic education for nursing professionals should be encouraged in order to raise awareness about their professional qualifications and independent role in providing care. Alongside enhancing information and communication regarding nursing responsibilities to challenge gender stereotypes, the importance of representation should be underscored, urging a thoughtful approach in the recruitment of nursing students to actively increase male representation in the field. Further research should focus on understanding patients’ needs and improving their healthcare experiences, which can be facilitated by a better understanding of the nursing role and competencies. By taking these factors into consideration, we can develop a more comprehensive understanding of the complex landscape of perceptions surrounding the nursing profession and pave the way for future research endeavors, as well as tackle gender misconceptions surrounding this profession.

Conclusions

The findings gleaned from this study offer valuable insights into the perceptions of the nursing profession from different angles. Firstly, the general population's recognition of the significance of nursing and their appreciation for the pivotal role nurses play in delivering patient care underscore the growing societal acknowledgment of the profession's importance. This positive sentiment toward nursing reflects the evolving dynamics of healthcare where the contributions of nurses are being increasingly valued and acknowledged. However, a contrasting sentiment emerges when examining the perceptions of patients. This group demonstrated a somewhat less favorable outlook in our study, revealing a deficiency in understanding the comprehensive scope of work and the educational qualifications of nursing professionals. This discrepancy suggests the need for improved communication and education initiatives directed toward patients, ensuring they are better informed about the competencies and responsibilities of nurses. Bridging this knowledge gap could potentially lead to more informed and collaborative patient–provider relationships.

Delving into the data analysis and incorporating insights from pertinent literature, a more profound comprehension of the nursing profession's journey comes to light. From its historical origins, nursing has evolved from a traditional and often narrowly perceived role to one that encompasses a myriad of specialized skills and responsibilities. This progression mirrors the changing landscape of healthcare, where nursing has grown to become an indispensable component of patient care. One notable finding is the presence of biases and uncertainties within both the general population and patients concerning the traditional nomenclature associated with nursing, which impacts perceptions of the profession's scope and historical contributions. This definitely underscores the importance of effective communication and education strategies to disentangle these biases and provide a more accurate understanding of the contemporary nursing profession. Intriguingly, this study uncovers a positive and progressive shift in the perception of males in nursing roles. This indicates a greater societal acceptance of gender diversity within professions that have historically been gender-stereotyped. The newfound recognition of males in nursing reinforces the need to challenge preconceived notions and promote inclusivity across traditionally gender-specific roles.

To conclude, the study's outcomes reveal a multifaceted tapestry of perceptions toward nursing as a profession. While the general population's acknowledgment and appreciation imply a positive trend toward recognizing nursing's significance, patients’ less favorable perceptions highlight the necessity for tailored educational initiatives. This comprehensive understanding, coupled with historical context and the shift in perceptions toward gender diversity, sets the stage for proactive efforts to enhance the image of the nursing profession, fostering collaboration, appreciation, and a more accurate understanding of its pivotal role in modern healthcare.

Footnotes

Acknowledgments

The authors extend sincere gratitude to all the participants who voluntarily took part in this research, as well as to the institutions that approved the conduct of the study.

Ethical Statement and Informed Consent

The research was conducted in accordance with the ethical standards of the institutional research board. Permissions to conduct the research were granted by the authors’ academic institution (under a thesis reference number 234/SSD/2023). All procedures that were followed adhered to the ethical standards of the Helsinki Declaration from 1975 and its revision in 2000. Written approval for questionnaire distribution was obtained from the healthcare institution and the NGO for individuals affected by diabetes. Additionally, approval was obtained from the Ethics Committee of the elderly care home. In both statements, the researchers committed to upholding the principles of data confidentiality, using the obtained data solely for the purpose of the specified research, and ensuring that published data would not allow the identification of any individual who participated in the study. All research participants were informed verbally and in writing about the purpose of the research and inclusion criteria, and by signing the informed consent, they confirmed their voluntary participation in the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Danijela Sopić

Tomislav Meštrović

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